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Source: Parker RB, Cavallari LH. Systolic Heart Failure. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed June 29, 2012.

  • Congestive heart failure (CHF)

  • Reduced myocardial contractility that results in inability of heart to pump sufficient blood to meet body’s metabolic needs.

  • Reduction in muscle mass (e.g., myocardial infarction [MI])
  • Dilated cardiomyopathies
  • Ventricular hypertrophy caused by pressure overload (e.g., systemic or pulmonary hypertension, aortic or pulmonic valve stenosis) or volume overload (e.g., valvular regurgitation, shunts, high-output states)

  • Neurohormonal model:
    • An initiating event (e.g., acute MI) leads to decreased cardiac output.
    • HF progression is mediated largely by neurohormones and autocrine/paracrine factors:
      • Angiotensin II
      • Norepinephrine
      • Aldosterone
      • Natriuretic peptides
      • Arginine vasopressin
      • Endothelin peptides
      • Proinflammatory cytokines such as tumor necrosis factor α and endothelin-1.

  • Nearly 6 million Americans have HF and 670,000 new cases are diagnosed each year.
  • Incidence doubles with each decade of life and affects nearly 10% of individuals over age 75.

  • Prevention involves identifying and modifying risk factors

  • Coronary artery disease
  • Hypertension
  • Chronic kidney disease
  • Smoking

Signs and Symptoms

  • Symptoms:
    • Dyspnea on exertion
    • Fatigue
    • Exercise intolerance
    • Orthopnea
    • Paroxysmal nocturnal dyspnea
    • Tachypnea
    • Cough
  • Signs:
    • Crackles
    • S3 gallop
    • Cool extremities
    • Cheyne–Stokes respiration
    • Tachycardia
    • Narrow pulse pressure
    • Cardiomegaly
    • Peripheral edema
    • Jugular venous distention
    • Hepatojugular reflux
    • Hepatomegaly

Means of Confirmation and Diagnosis

  • Consider HF diagnosis in patients with characteristic signs and symptoms; perform medical history and physical examination with appropriate laboratory testing.
  • New York Heart Association Functional Classification System
    • I: No limitation of physical activity
    • II: Slight limitation of physical activity
    • III: Marked limitation of physical activity
    • IV: Unable to carry on physical activity without discomfort
  • American College of Cardiology/American Heart Association (ACC/AHA) staging system
    • Stage A: At high risk for developing heart failure
    • Stage B: Structural heart disease but no HF signs or symptoms
    • Stage C: Structural heart disease and previous or current HF symptoms
    • Stage D: Refractory HF (symptoms at rest despite maximal medical therapy)

Laboratory Tests

  • Complete blood cell count (CBC)
  • Serum electrolytes (including calcium and magnesium)
  • Renal, hepatic, and thyroid function tests
  • Urinalysis
  • Fasting lipid profile
  • A1C
  • B-type natriuretic peptide (BNP)


  • Ventricular hypertrophy on chest radiograph or electrocardiogram (ECG).
  • Chest radiograph may show pleural effusions or pulmonary edema.
  • Echocardiogram to identify abnormalities of pericardium, myocardium, or heart values and quantify left ventricular ejection fraction (LVEF).

Differential Diagnosis

  • Improve quality of life.
  • Relieve or reduce symptoms.
  • Prevent or minimize hospitalizations.
  • Slow disease progression.
  • Prolong survival.

  • Identify and treat underlying causes or precipitating factors.
  • ACC/AHA stage A
    • Identify and modify risk factors to prevent structural heart disease and subsequent HF.
    • Use angiotensin-converting ...

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